Reports > The Health Care Workforce in Eight States: Education, Practice & Policy > Colorado

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On this page: Project Description | Study Methodology | State Summary | Workforce Supply and Demand | Health Professions Education | Physician Practice Location | Licensure and Regulation of Practice | Improving the Practice Environment | Exemplary Workforce Legislation, Programs and Studies | Policy Analysis | Data Sources

Historically, both federal and state governments have had a role in developing policy to shape the health care workforce.  The need for government involvement in this area persists as the private market typically fails to distribute the health workforce to medically underserved and uninsured areas, provide adequate information and analysis on the nature of the workforce, improve the racial and ethnic cultural diversity and cultural competence of the workforce, promote adequate dental health of children, and assess the quality of education and practice. 

It is widely agreed that the greatest opportunities for influencing the various environments affecting the health workforce lie within state governments. States are the key actors in shaping these environments, as they are responsible for:

§ financing and governing health professions education;

§ licensing and regulating health professions practice and private health insurance;

§ purchasing services and paying providers under the Medicaid program; and

§ designing a variety of subsidy and regulatory programs providing incentives for health professionals to choose certain specialties and practice locations.

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  This initiative to compile in-depth assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues, influences and policies. 

Products of this study include individual health workforce assessments for each of the eight states and a single assessment that compares various data and influences across the eight states.  In general, each state assessment provides the following:

1) A summary of health workforce data, available resources and a description of the extent the state invests in collecting workforce data.  [Part of this information has been provided by the Bureau of Health Professions];

2) A description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions education, service placement and reimbursement, planning and monitoring, and licensure/regulation;

3) An assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences; and

4) An analysis of the policy implications of the state’s current workforce data, issues, capacity and strategies.

The development of the project’s data assimilation strategy, content and structure was guided by an expert advisory panel.  Members of the advisory panel included both experts in state workforce policy (i.e., workforce planners, researchers and educators) and, more broadly, influential state health policymakers (i.e., state legislative staff, health department officials).  The advisory panel has helped to ensure the workforce assessments have an appropriate content and effective format for dissemination and use by both state policymakers and workforce experts/officials.

STUDY METHODOLOGY

Study Purpose and Audience

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  Because states increasingly are being looked to by the federal government and others as proving grounds for successful health care reform initiatives, new and dynamic mechanisms for sharing innovative and effective state workforce strategies between states and with the federal government must be implemented in a more frequent and far reaching manner.  This initiative to compile comprehensive capacity assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues and influences.

Each state workforce assessment report is not intended to be voluminous; rather, information is presented in a concise, easy-to-read format that is clearly applicable and easily digestible by busy state policymakers as well as by workforce planners, researchers, educators and regulators.

Selection of States

NCSL, with input from HRSA staff, developed a methodology for identifying and selecting 8 states to assess their health workforce capacity.  The methodology included, but was not limited to, using the following criteria:

a.   States with limited as well as substantial involvement in one or more of the following areas: statewide health workforce planning, monitoring, policymaking and research;

b.   States with presence of unique or especially challenging health workforce concerns or issues requiring policy attention;

c.   States with little involvement in assessing health workforce capacity despite the presence of unique or especially challenging health workforce concerns or issues requiring policy attention;

d.   Distribution of states across Department of Health and Human Services regions;

e.   States with Bureau of Health Professions (BHPr) - supported centers for health workforce research and distribution studies;

f.   States with primarily urban and primarily rural health workforce requirements; and

g.   States in attendance at BHPr workforce planning workshops or states that generally have interest in workforce modeling.

Collection of Data

NCSL used various means of collecting information for this study.  Methods exercised included:

a. Phone and mail interviews with state higher education, professions regulation, and recruitment/retention program officials;

b. Custom data tabulations by national professional trade associations and others (i.e., Quality Resource Systems, Inc.; Johns Hopkins University School of Public Health) with access to national data bases;

c. Tabulations of data from the most recent edition of federal and state government databases (e.g., National Health Service Corps field strength);

d. Site visit interviews with various officials in the ten  profile states;

e. Personal phone conversations with other various state and federal government officials;

f.   Most recently available secondary data sources from printed and online reports, journal articles, etc.; and

g. Comments and guidance from members of the study’s expert advisory panel.

STATE SUMMARY

Colorado’s population is rapidly becoming urban and more minority in composition.  The percent of children without health insurance is rising and is now above the national average.  Perhaps related to this trend, the percent of the population that resides in federally designated health professional shortage areas (HPSAs) is below the U.S. average.  The ratio of National Health Service Corps professionals per 10,000 population living in the state’s HPSAs exceeds the national average, as does the state’s number of physicians, nurse practitioners, dentists, and dental hygienists per 100,000 total population.

Before the 2001 legislative session, the state had not in recent years addressed health workforce issues in a significant way.  In 2001, a new law allows physicians and hospitals to establish their own networks to provide health coverage and bypass insurance companies.  Also, various telemedicine services are now reimbursable under the state’s Medicaid programs, which states that no health benefit plan pertaining to individuals residing in counties with fewer than 150,000 population may require face-to-face provider to patient contact, but instead such care can appropriately be delivered through telemedicine if the county has the necessary technology.  Also important to improving provider availability in rural areas, the legislature in 2001 amended the allowable tax credit for health professionals practicing in rural HPSAs to alter the rural underserved definition and expand the number of eligible health professionals to include dentists and dental hygienists.  A 2002 bill would make such a tax credit permanent and would expand further the list of eligible health professionals to include registered and licensed practical nurses and pharmacists.

Health workforce shortage issues are now an important concern for the legislature.  Health care in general is likely to be debated often in the 2002 election for governor.  However, growing fiscal constraints are likely to limit the state’s actions to address the workforce shortage issue.

As in other states, Colorado is experiencing a growing shortage of practicing nurses in both its rural and urban areas.  Beginning in 1999, HealthONE Alliance, a non-profit partner in metro Denver’s largest hospital system, convened a collaborative group of statewide health care stakeholders, including the state hospital and nursing associations, to examine the state’s nursing workforce supply.    In 2001, the Alliance agreed to fund in 2002 the creation of a statewide nursing center of excellence that would serve as a central clearinghouse for workforce data, best practices and career development information.  Other major activities to address nurse shortage concerns involve the state hospital association, the Colorado Area Health Education Centers, the University of Colorado, and the state nurses association.

Recent surveys of practicing dentists and dental hygienists indicate a growing number of dentists are nearing retirement, particularly in rural communities.  At least 11 counties in the state now lack a dentist.  Significant attention has been given in recent years to addressing rising concerns about a lack of access to dental care in Colorado, particularly in the state’s rural and underserved communities.   In 2001, the Legislature created a dental loan repayment program to encourage and recruit new dentists to provide service to underserved populations.  An appropriation of $200,000 in tobacco settlement funds was made to fund the new program beginning in April 2002. Also in 2001, a law was enacted that authorizes services provided by hygienists to children without the supervision of a licensed dentist to be covered by Medicaid and with payment to be made directly to the hygienist.  Such independent practice of a hygienist has been allowed under their practice act for about 15 years.

I.  WORKFORCE SUPPLY AND DEMAND

Arguably, it is most important initially to understand the marketplace for a state’s health care workforce.  How many health professionals are in practice statewide and in medically underserved communities?  What are the demographics of the population served?  How is health care organized and paid for in the state?  This section attempts to answer some of these questions by presenting state-level data collected from various sources.

* As defined by the U.S. Office of Management and Budget

Sources:  U.S. Census Bureau, AARP.

Although more than 80% of Colorado residents live in metropolitan areas, less than a quarter of the state’s population are minorities.

Sources : CDC, AARP, GAO.

Less than half of Colorado families with an annual family income under $15,000 visited a dentist in the previous year.

HPSA = Health Professional Shortage Area

* It is commonly believed that there are additional areas in the state that may be eligible to receive HPSA designation.

Sources : KFF, AARP, BPHC-DSD.

Colorado has a higher proportion of children who are uninsured than the U.S average. However, compared to the U.S. as a whole, Colorado has a lower proportion of persons living in primary care and dental HPSAs.

RN= Registered Nurse, LPN= Licensed Practical Nurse, CNM= Certified Nurse Midwife, NP= Nurse Practitioner

CRNA= Certified Registered Nurse Anesthetist

Source : HRSA-BHPr.

Colorado has more nurse practitioners and certified nurse midwives per 100,000 population than the U.S. as a whole. Only 6% of physicians in the state are international medical graduates.

HPSA= Health Professional Shortage Area

Source : BHPr-NHSC.

Colorado has more NHSC professionals per 10,000 population in HPSAs than the national average.

MCOs = Managed Care Organizations    HMOs = Health Maintenance Organizations    OB/GYN = Obstetrician/Gynecologist

* This requirement does not preclude MCOs from including additional professions on their provider panels.

Sources : HPTS, AARP.

Colorado has a higher HMO penetration rate than the U.S. average.

¹ Generally seen as an indicator of significant participation in the Medicaid program.

² Denominator number from HRSA State Health Workforce Profile, December 2000.

*  Numerator data for physicians and nurse practitioners from state Medicaid agencies were unusable: many professionals were apparently double-counted, perhaps due to varying participation in different health plans.

Sources : State Medicaid programs, Norton and Zuckerman “Trends”, HPTS, AARP.

Less than 2% of dentists enrolled in Medicaid in Colorado receive payments of more than $10,000 annually.  There have been no payment rate increases for any of the professions of greater than 10% in the five years.

II.  HEALTH PROFESSIONS EDUCATION

State efforts to help ensure an adequate supply of health professionals can be understood in part by examining data on the state’s health professions education programs–counts of recent students and graduates, amounts of state resources invested in education, and other factors.  State officials can gauge how well these providers reflect the state’s population by also examining how many students and graduates are state residents or minorities.  Knowing to what extent states are also investing in primary care education and how many medical school graduates remain in-state to complete residencies in family medicine is also important.

Sources: AAMC, AAMC Institutional Goals Ranking Report, AACOM, Barzansky et al. “Educational Programs”, State higher education coordinating boards.

Almost 90% of newly entering medical students in Colorado are state residents. Over one-third of the state’s medical school graduates entered generalist specialties from 1987-1993.

² Does not include residents from Canada.

³ Explicit payments for both direct and indirect GME cost.

⁴ Funds largely are for graduate education.

⁵ Dollar amounts refer largely to funding for family medicine training programs. However, these funds that flow directly to teaching hospitals are not necessarily earmarked by the state for graduate medical education.

Sources : AMA, AMA State-level Data, AACOM, State higher education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”

Only 5% of Colorado’s physician residents are international medical graduates.

¹ Denominator number is state population from 2000 U.S. Census.

2 Dollar amounts refer largely to funding family medicine training programs. However, these funds that flow directly to teaching hospitals are not necessarily earmarked by the state for graduate medical education.

Sources: AAFP, AAFP State Legislation, Kahn et al., Pugno et al. and Schmittling et al. “Entry of U.S. Medical School Graduates”.

Colorado has a higher percentage of graduates who were first year residents in family medicine than the U.S. as a whole.  Over half of Colorado graduates who chose an in-state family residency program between 1995-2000, entered an in-state family medicine residency.

¹ Annual figure for Associate, Baccalaureate, Masters and Doctoral students/graduates for most recent years available.

² Denominator number is the state population from the 2000 U.S. Census.

Sources: NLN, AACN, State higher education coordinating boards.

Enrollment in Colorado’s baccalaureate and doctoral degree nursing programs decreased slightly between 1999 and 2000.  Enrollment in master’s degree programs increased slightly during the same time period.

* Denominator number is state population from 2000 U.S. Census.

Source: AACP.

¹ Denominator number is state population from 2000 U.S. Census.

² In general, state appropriations are not directly earmarked for these programs, but rather to their sponsoring institutions.

Sources: APAP, APAP Annual Report.

* Denominator number is state population from 2000 U.S. Census.

Source: ADA.

* Denominator number is state population from 2000 U.S. Census.

Sources: ADHA, AMA Health Professions.

III.  PHYSICIAN PRACTICE LOCATION

The following tables examine in-state physician practice location from two different vantage points: (1) of all physicians who were trained (went to medical school or received their most recent GME training) in the state between 1975 and 1995, and (2) of all physicians who are now practicing in the state, regardless of where they were trained.  Complied from the American Medical Association’s 1999 Physician Masterfile by Quality Resource Systems, Inc., the data importantly illustrates to what extent physician graduates practice in many of the state’s small towns, using the rural-urban continuum developed by the U.S. Department of Agriculture.

Practice location (URBAN/ RURAL) of physicians who received their ALLOPATHIC medical school training in COLORADO between 1975 and 1995

¹ 1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:      

00: Central counties of metro areas of 1 million or more
01: Fringe counties of metro areas of 1 million or more
02: Counties with metro areas of 250,000 - 1 million
03: Counties in metro areas of less than 250,000
NA: Not Applicable; no counties in the state are in the R/U Continuum Code
Codes # 04-09 indicate non-metropolitan counties:
04: Urban population of 20,000 or more, adjacent to metro area
05: Urban population of 20,000 or more, not adjacent to metro area
06: Urban population of 2,500-19,999, adjacent to metro area
07: Urban population of 2,500-19,999, not adjacent to metro area
08: Completely rural (no place w population > 2,500), adjacent to metro area
09: Completely rural (no place w population > 2,500), not adjacent to metro area

Practice location (URBAN/RURAL) of physicians who received their most recent GME training in COLORADO between 1978 and 1998

¹  1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale.  Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more
01: Fringe counties of metro areas of 1 million or more
02: Counties with metro areas of 250,000 - 1 million
03: Counties in metro areas of less than 250,000
Codes # 04-09 indicate non-metropolitan counties:
04: Urban population of 20,000 or more, adjacent to metro area
05: Urban population of 20,000 or more, not adjacent to metro area
06: Urban population of 2,500-19,999, adjacent to metro area
07: Urban population of 2,500-19,999, not adjacent to metro area
08: Completely rural (no place w population > 2,500), adjacent to metro area
09: Completely rural (no place w population > 2,500), not adjacent to metro area
NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

IV.  LICENSURE AND REGULATION OF PRACTICE

States are responsible for regulating the practice of health professions by licensing each provider, determining the scope of practice of each provider type and developing practice guidelines for each profession.  The tables below illustrate the licensure requirements for each of the health professions covered in this study as well as additional information on recent expansions in scope of practice or other novel regulatory measures taken by the state.

Sources : State licensing board, HPTS.

Source: State licensing board

Sources : State licensing board, AANA, ACNM, Pearson “Annual Legislative Update”, HPTS.

Source : State licensing board.

Source : State licensing board.

Source : State licensing board, ADHA.

Glossary of Acronyms

CNM: Certified nurse midwife.
CRNA: Certified registered nurse anesthetist.
NP: Nurse practitioner.

V.   IMPROVING THE PRACTICE ENVIRONMENT

States have the challenge of not only helping to create an adequate supply of health professionals in the state, but also ensuring that those health professionals are distributed evenly throughout the state.  Various programs and incentives are used by states to encourage providers to practice in rural and other underserved areas.  The tables in this section describe Colorado’s programs as well as the perceived effectiveness of these programs.

RECRUITMENT/ RETENTION INITIATIVES

Source : State health officials.

Most of Colorado’s workforce recruitment and retention efforts in rural or underserved areas are focused on physicians. The state does however have placement programs for all of the health professions.

LOAN REPAYMENT/ SCHOLARSHIP PROGRAMS *

* Includes only state-funded programs which require a service obligation in an underserved area.  (NHSC state loan repayment programs are included since the state provides funding.)

Source : State health officials.

WORKFORCE PLANNING ACTIVITIES*